ࡱ> ]_\` Jbjbj *pn  ****ln*aF+,.,.,.,.35A6\Z,``````$6bhd`]620366`,.,.W:a8886 ,.,.W=286Z888,.:+ Dls*689TPa0a84e64e84e8466866666``8 666a6666d**6a MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION FINANCIAL INFORMATION REQUEST DATE  FORMTEXT  DATE \@ "MM/dd/yyyy" 06/17/200505/05/2004COUNTY OFFICE  FORMTEXT      CASE NAME  FORMTEXT      ADDRESS  FORMTEXT      CASE NUMBER  FORMTEXT      CITY, STATE, ZIP  FORMTEXT       ADDRESS  FORMTEXT      PHONE  FORMTEXT    - FORMTEXT    - FORMTEXT       FORMTEXT      FINANCIAL INSTITUTION NAME  FORMTEXT      CASEWORKER  FORMTEXT      ADDRESS  FORMTEXT       LOAD NO.  FORMTEXT      INSTRUCTIONS TO FINANCIAL INSTITUTIONWe are determining eligibility or completing an assessment of assets in the above referenced case. We have provided the social security numbers, names and known account numbers for members of the case. This request is for financial information on all accounts of these persons. A self-addressed stamped envelope is enclosed for your convenience.AUTHORIZATION FOR RELEASE OF INFORMATIONHEAD OF HOUSEHOLD/PAYEE NAME  FORMTEXT      SOCIAL SECURITY NO.  FORMTEXT    - FORMTEXT   - FORMTEXT     SIGNATUREDATE SIGNED SPOUSE/OTHER JOINT OWNER  FORMTEXT      SOCIAL SECURITY NO.  FORMTEXT    - FORMTEXT   - FORMTEXT     SIGNATUREDATE SIGNEDNAME  FORMTEXT      SOCIAL SECURITY NO.  FORMTEXT    - FORMTEXT   - FORMTEXT     SIGNATUREDATE SIGNEDFINANCIAL INFORMATION REQUESTEDPlease provide information for the account numbers listed and any other Checking Accounts, Savings Accounts, Certificates of Deposit, Christmas Funds. Trust Accounts, any type of Individual Retirement Accounts, or other accounts of the persons named above. ACCOUNT NUMBER FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT   2 4 6 8 L N R n p 濵{q]{I{&jh0QCJOJQJUmHnHu'jh0Qh0QCJOJQJUh0QCJOJQJjh0QCJOJQJUhgKCJmHnHujhgKhgKCJUhCJmHnHu hgKCJjhgKCJUhgKCJ OJQJhgK5CJOJQJhgKOJQJhgKCJOJQJhgKjhgKUjhgKUmHnHu XP $If <$If^ $If^ JP R n vpvp$If $If^~kdV$$IflrBA #*4 la  $ & : < > H J L N p 쪠xnhXnHnjhgKCJUmHnHujbhgKhgKCJU hgKCJjhgKCJU&jh0QCJOJQJUmHnHu'jh0Qh0QCJOJQJUh0QCJOJQJjh0QCJOJQJUhgKjh0QCJUmHnHujh0Qh0QCJU h0QCJjh0QCJUhgKCJ OJQJhgKCJOJQJ $ L N p _Gkd$$Ifl 0&*d4 la$If $If^GkdG$$Ifl 0&*d4 la p r     񵫥siUsAsisi&jhgKCJOJQJUmHnHu'jvhgKhgKCJOJQJUhgKCJOJQJjhgKCJOJQJUhgKjh0QCJUmHnHuj-h0Qh0QCJU h0QCJjh0QCJUhgKCJ OJQJ&jh0QCJOJQJUmHnHu'jh0Qh0QCJOJQJUh0QCJOJQJjh0QCJOJQJU N P R z | _Gkd$$Ifl 0&*d4 la $If^Gkd$$Ifl 0&*d4 la$If    $ & ( * > @ B J L N R T h j l v x z |  ݿݿݡ{kgWkjqh0Qh0QCJUhgKjh0QCJUmHnHujh0Qh0QCJU h0QCJjh0QCJU hgKCJhgKCJ OJQJ'j,hgKhgKCJOJQJUhgKCJOJQJ&jhgKCJOJQJUmHnHujhgKCJOJQJU'jRhgKhgKCJOJQJU   * R T f _Gkd #$$IflH0#*H$4 laGkdw $$Ifl 0*N 4 la$If $If^       * , @ B D N P f h | ~ ghk˧vj^TvThgKCJOJQJhgK@CJOJQJhgK@CJOJQJhgK5CJOJQJjhgKCJUmHnHuj "hgKhgKCJU hgKCJjhgKCJUj!h0Qh0QCJU h0QCJhgKhgKCJ OJQJjh0QCJUmHnHujh0QCJUjqh0Qh0QCJU wm $If^4kd!$$$Ifl**4 la$($If^a$Dkd#$$Ifl**    4 lap    68LNPVXZ\prtxz|~ǡїqaqQj (hgKhgKCJUj'hgKhgKCJUjhgKCJUmHnHuj&hgKhgKCJU hgKCJjhgKCJUjh0QCJUmHnHuj%h0Qh0QCJU h0QCJjh0QCJUhgKCJ OJQJhgKhgK5CJOJQJhgKCJOJQJhgK5CJOJQJ6 $$Ifa$$If $If^Dkd|$$$Ifl**    4 lap (*TVjlvxzýÝ}pý`jX-h0Qh0QCJUj,hgKCJUjg+hgKCJUj*hgKCJU hgKCJjh0QCJUmHnHuj)h0Qh0QCJU h0QCJjh0QCJUhgKhgKCJ OJQJhgKCJOJQJjhgKCJUmHnHujhgKCJU%,Tx $$Ifa$$If $If^mkd*)$$Ifl \j&"* 4 la Hx $$Ifa$$If $If^mkd,$$Ifl \j&"* 4 laHJ^`bhjln "$.0rt&˻ѫ˞ˎѫۊukuk`k`khgK5CJOJQJhgKCJOJQJhgKCJOJQJhgK5CJOJQJhgKj/hgKhgKCJUjR/hgKCJUjhgKCJUmHnHujH.hgKhgKCJU hgKCJjhgKCJUhgKCJ OJQJjh0QCJUmHnHujh0QCJU""$(C6 $$If^a$Dkd1$$Ifl**    4 lap  $If^mkd1$$Ifl \j&"* 4 la&(*.JLNbdfprtv@@@@@@@8@:@<@@@ĹȫĠĕĊĈ}wqk hgKCJ hgKCJ hgKCJj4hgKUUj(4hgKUj3hgKUj83hgKUjhgKUmHnHuj2hgKUhgKjhgKUhgKCJOJQJhgKCJOJQJhgKCJOJQJ hgKCJ hgK5CJ OJQJ((*,.Lt@ $$Ifa$ $If^4kd+2$$IflH**4 la       TYPE OF ACCOUNT  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       NAMES ON ACCOUNTCURRENT BALANCE IF 0, ENTER DATE CLOSED AND AMOUNT WITHDRAWN BALANCE AS OF  FORMTEXT       AMOUNT OF INTEREST EARNED DATE INTEREST PAID PERIOD COVERED INTEREST RATEDIRECT DEPOSIT REQUEST Please make my assistance payment by direct deposit to my (checking) (savings) account. DIRECT DEPOSIT NAME TYPED  FORMTEXT      SIGNATUREDATE  FORMTEXT      BANK OFFICIAL Please enter transit routing number, account number and type of account for direct deposit below:TRANSIT ROUTING NUMBERACCOUNT NUMBERTYPE OF ACCOUNTCHECK AND GIVE DETAILS ON BACK IF ANY OF THE ABOVE LISTED PERSONS HAVE ANY OF THE FOLLOWING LARGE WITHDRAWALS SAFE DEPOSIT BOX LOANS OWED STOCKS BONDS TRUST DEEDS OWED ANY ADDITIONAL INFORMATION OR COMMENTS CONCERNING INVESTMENTS OR OTHER TRANSACTIONS WHICH YOU MAY HAVE HAD WITH THE ABOVE PERSONS WILL BE APPRECIATED. 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<1Vm[=SP.8N?îTzjWwRx!iWFk 8ĚUb RsV<&e ;KsmoA)(^ zj9i[/#:42;n0Tty{IaCUPQ͖!?kZ!z,ޟgXw{E'=TE#ҎAЖtx)(nVw[CiwQrt n\!7WVLj!Cw)}6gfcKg 0^pFϥSy5;2@Ԛޠ*ޑ<,?!YN=ğ ^=V xKJ~?P,U7W(O<]Ҷe*Qn71 #0S-ȵؿ=6ajco_!O6^\ng7'j6cemg FQo>jmtkO7tQ0j;vnk{)̨h?wY2,g}.Vûirz;L̽.6=+tzY.s|Zǟd| s313?\w-IENDB`DText9 MM/dd/yyyy$$If!vh55555#v#v#v#v#v:V l555554D IAgencyCopyShow7Toolbar.MAINDCaseNameEnter Claimant's full name$$If!vh55d#v#vd:V l 55d/  /  / 4DICountyMailingCopyDText4Enter claimant's case number$$If!vh55d#v#vd:V l 55d/  /  / 4DICountyCityStateZIPCDText6$Enter claimant's full street address$$If!vh55d#v#vd:V l 55d/ / / 4DICountyAreaCopy*Enter county office phone number area codeDICountyPrefixCopy'Enter county office phone number prefixDICountyPhoneCopy3Enter county office phone number (last four digits)DText30)Enter claimant's city, state and zip code$$If!vh55d#v#vd:V l 55d/ / /  4DText11EEnter the name of the institution from which information is requestedDCaseworkerNameCopy<The caseworker requesting the information will sign the form$$If!vh5N5 #vN#v :V l 5N5 / /  / 4DText12HEnter the address of the institution from which information is requestedDLoadNumberCopy>Enter the load number of the caseworker requesting information$$If!vh5H$5#vH$#v:V lH5H$5/ /  / 4$$If!vh5*#v*:V l  5*/  /  4p Y$$If!vh5*#v*:V l5*/  4$$If!vh5*#v*:V l  5*/  /  4p DText14CEnter the full name of the person for whom information is requestedDText13PEnter the Social Security number of the person for whom information is requested DPEnter the Social Security number of the person for whom information is requested DPEnter the Social Security number of the person for whom information is requested$$If!vh555 5#v#v#v #v:V l 555 5/  4DCEnter the full name of the person for whom information is requestedDText13PEnter the Social Security number of the person for whom information is requestedDPEnter the Social Security number of the person for whom information is requestedDPEnter the Social Security number of the person for whom information is requested$$If!vh555 5#v#v#v #v:V l 555 5/ 4DCEnter the full name of the person for whom information is requested DPEnter the Social Security number of the person for whom information is requestedDPEnter the Social Security number of the person for whom information is requested DPEnter the Social Security number of the person for whom information is requested$$If!vh555 5#v#v#v #v:V l 555 5/ 4$$If!vh5*#v*:V l  5*/  /  4p Y$$If!vh5*#v*:V lH5*/ 4DText19Enter any known account numberxDEnter any known account numberxDEnter any known account numberxDEnter any known account number~DText19Enter any known account number$$If!vh555555#v#v#v:V l 555/  /  / 4DText24 TITLE CASEEnter the type of account}D Title CaseEnter the type of account}D Title CaseEnter the type of accountDText24 Title CaseEnter the type of accountDText24 Title CaseEnter the type of account$$If!vh555555#v#v#v:V l 555/  /  / / 4$$If!vh555555#v#v#v:V l 555/  /  / 4$$If!vh555555#v#v#v:V l 555/  /  / 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